Clinical effectiveness of the START (STrAtegies for RelaTives) psychological intervention for family carers and the effects on the cost of care for people with dementia: 6-year follow-up of a randomised controlled trial

Background: The START (STrAtegies for RelaTives) intervention reduced depressive and anxiety symptoms of family carers of relatives with dementia at home over 2 years and was cost-effective. Aims:To assess the clinical effectiveness over 6 years and the impact on costs and care home admission. Method: We conducted a randomised, parallel group, superiority trial recruiting from 4 November 2009 to 8 June 2011 with 6-year follow-up (trial registration: ISCTRN 70017938). A total of 260 self-identified family carers of people with dementia were randomised 2:1 to START, an eight-session manual-based coping intervention delivered by supervised psychology graduates, or to treatment as usual (TAU). The primary outcome was affective symptoms (Hospital Anxiety and Depression Scale, total score (HADS-T)). Secondary outcomes included patient and carer service costs and care home admission. Results: In total, 222 (85.4%) of 173 carers randomised to START and 87 to TAU were included in the 6-year clinical efficacy analysis. Over 72 months, compared with TAU, the intervention group had improved scores on HADS-T (adjusted mean difference −2.00 points, 95% CI −3.38 to −0.63). Patient-related costs (START versus TAU, respectively: median £5759 v. £16 964 in the final year; P = 0.07) and carer-related costs (median £377 v. £274 in the final year) were not significantly different between groups nor were group differences in time until care home (intensity ratio START:TAU was 0.88, 95% CI 0.58–1.35). Conclusions: START is clinically effective and this effect lasts for 6 years without increasing costs. This is the first intervention with such a long-term clinical and possible economic benefit and has potential to make a difference to individual carers

Making decisions for people with dementia who lack capacity: qualitative study of family carers in UK

Objective To identify common difficult decisions made by family carers on behalf of people with dementia, and facilitators of and barriers to such decisions, in order to produce information for family carers about overcoming barriers

Risk assessment for people living with dementia: a systematic review.

Abstract Objective: This systematic review identified key components of risk assessment for people with dementia, examined attitudes towards risk identification and risk assessment, and appraised existing risk assessment tools. Methods: Systematic searches of five databases on two platforms (EBSCO, OVID) and grey literature databases (Open Grey, Base) were conducted. Studies were screened for inclusion based on predetermined eligibility criteria and quality assessed using the Mixed Methods Appraisal Tool. Findings were tabulated and synthesised using thematic synthesis. Results: Our review found people with dementia, their family carers, and healthcare professionals differed in how risk is conceptualised, with views being shaped by media perceptions, personal experiences, sociocultural influences, dementia knowledge and dementia severity. We found that mobilisation (causing falls inside and getting lost outside) is the most frequently identified risk factor. Our findings show people with dementia are generally risk-tolerant, while healthcare professionals may adopt risk-averse approaches because of organisational requirements. We found factors that disrupt daily routines, living and caring arrangements, medication management, and unclear care pathways contribute towards adverse risk events. We discovered that most studies about risk and risk assessment scales did not consider insight of the person with dementia into risks although this is important for the impact of a risk. No risk instrument identified had sufficient evidence that it was useful. Conclusion: Accurate risk assessment and effective communication strategies that include the perspectives of people with dementia are needed to enable risk-tolerant practice. No risk instrument to date was shown to be widely acceptable and useful in practice

Persecutory Symptoms and Perceptual Disturbance in a Community Sample of Older People: the Islington Study

Background While there are extensive studies of paranoid symptoms and perceptual disturbance (PPD) in younger adults, relatively little is known about older adults with similar symptoms. Method This study took place in Islington, an inner London borough. Enumeration Districts were I:randomised to prc,vide a sampling frame. Residents aged 65 or over were interviewed at home. The Short-CARE was used to elicit psychiatric symptoms and diagnosis. Sociodemographic particulars were elicited using the Client Sociodemographic and Service Receipt Inventory. Questions were asked regarding sight and hearing. We used subsections of the geriatric mental scale to identify people who had PPD symptoms. Medications taken were recorded. We asked 'Do you have any health problems'." as a screening question for subjective health problems. Results We interviewed 720 people. Twenty-eight (3.9%) participants scored positively on the PPD sub-scales of the GMS. A forward logistic regression analysis for independent predictors of PPD found the significant independent predictors were dementia (p = 0.0000: odds ratio 6.8), drinking alcohol in last 6 months (p < 0.03: odds ratio 0.3). drinking alcohol to help sleep (p < 0.005; odds ratio 9.6), subjective memory loss (p < 0.007: odds ratio 3.3) and uncorrected visual impairment (p < 0.02; odds ratio 2.8). Conclusion There is a relatively high prevalence of PPD in older people living in the community. This is not associated with higher use of services despite the increased needs. Further studies should consider interventions to meet this unmet need. Copyright (C) 2001 John Wiley & Sons, Ltd

Accessibility of health and social services to immigrant elders: The Islington Study

Background Numbers of immigrant elders are increasing and it is unclear whether they can access services. Aims To examine service utilisation of older immigrants compared with their UK-born counterparts and relate it to health difficulties. Method Cross-sectional study in inner London measuring service use, mental health and disability. Results A total of 1085 people aged greater than or equal to65 years were interviewed. Independent predictors of contact with a general practitioner included being born in Cyprus, Cypriots were the only immigrant population to report significantly more somatic symptoms than those born in the UK (P=0.005). Africans and Caribbeans used day care and other social services most frequently. Conclusions Immigrants could access services. Africans and Caribbeans appear to have poorer physical health and thus have greater contact with services, Cypriots who experience depression may present with prominent somatic symptoms. This is likely to be due to a different idiom of distress

Slicing the health service cake: the Islington study

Background: little is known about the factors that are associated with receipt of care in older people. This study aims to describe the pattern and predictors of service usage, by a representative sample of people aged 65 and over. Method: we assessed psychiatric and physical morbidity, formal and informal care and prescribed medication by standardized questionnaires. Results: 1085 people were interviewed at home. Having dementia was a negative predictor of GP and hospital consultation (both P<0.001). Depressed participants were most likely to consult with GPs (P<0.05); 13.1% were on antidepressants. People with dementia use health services less than their counterparts. The presence of co‐resident informal caregivers predicts less use of social services but no increase in health consultations. Conclusions: carers give compensatory care rather than act as bridges to link people with dementia with the health care system. People with dementia need advocates. Older people with depression are high users of all services. They remain under‐treated pharmacologically

Mental Health of Migrant Elders — The Islington Study

Background In the UK, 6% of those aged 65 years and over were born abroad, most of whom now live in inner-city areas. It has been suggested that ethnic elders are particularly vulnerable to mental illness. Aims To compare the prevalence of dementia and depression in older migrants with those born in the UK. Method A cross-sectional community study of 1085 people aged 65 years or older in an inner-London borough. Results Compared with those born in the UK, the prevalence of dementia was raised in African-Carib beans (17.3%, relative risk=1.72, CI=1.06-2.81) and lower for the Irish-born (3.6%, relative risk=0.36,CI=0.17-0.87). All those of African-Caribbean country of birth were significantly younger (P=0.000) but no more likely to be taking antihypertensive drugs. They were no more likely to report having cardiovascular problems but had increased rates of diabetes (P < 0.0000). The overall prevalence of depression was 18.3% (95% CI=16.1-20.7). The highest prevalence rate was found among those born in Greece and Turkey (27.2%, CI=17.9-39.6). Migration per se does not appear to be a risk for depression and dementia in this population. Conclusions The excess of dementia may be of vascular aetiology. There is the potential for primary or secondary prevention